May 19, 2011

Incidentalomas revisited

Dr. Bruce Friedman posted a thoughtful blog on Lab Soft News recently concerning "incidentalomas" ("How to Avoid the Risks of a CT Incidentaloma"). This post happened to coincide with a new working committee at my hospital commissioned with developing a virtual clinic for following patients who have incidental lung nodules discovered.

Perhaps unlike other sites, there are widely disseminated radiographic recommendations for following lung nodules (Fleishner criteria). Of interest, a recent article found that despite widespread awareness of these criteria, actual incorporation of these criteria into practice has been found wanting--only around 50% of radiology practices actually used these recommendations in reports. One issue that we will be challenged with is how to track these patients across multiple different providers for appropriate follow-up. One model we are considering is already in place: using a breast "navigator" to follow-up patients with abnormal mammograms. This issue arose recently because of a series of patients presented at our Tumor Board who had incidental lung nodules identified but were not followed appropriately and then were re-discovered with inoperable advanced stage disease months later.

This idea also came up just today in a conversation I was having with a urologist colleague regarding renal incidentalomas treated with cryoablation. I recently diagnosed an incidentally discovered 2.5-cm mass in an 80-year-old woman on CT-guided needle biopsy as an muscle-predominant angiomyolipoma (mini-case report on its way!). For better or worse, the tumor was ablated probable before it was even grossed! But, to return to Dr. Friedman's post, what if the patient was simply observed with serial imaging? The urologist was unaware of any recommendations similar to the Fleishner criteria for lung nodules. If you, dear reader, know of any please post them in a comment.

Finally, today's email brought a "Published Ahead of Print" article from Journal of Thoracic Oncology on-- mediastinal incidentalomas. This is a prospective study of 88 patients in which mediastinal lymphadenopathy was found as an incidental finding on CT scans for indications other than staging. The title is a bit deceptive but the scenario is common. The finding of incidental mediastinal lymph nodes on CT were characterized by multiple Naruke stations involved, relative small sizes of nodes (median ranging from 6 to 14 mm for all nodes), and coexistence with hilar adenopathy. In this study, sarcoidosis was diagnosed by EBUS-FNA in 22% of patients and 2 patients developed lung cancer 2 years after initial finding.

While I concur with the basic premise of the post (i.e. that one shouldn't jump into a full-blown diagnostic work-up of an incidental finding), I think we should also insist on developing evidence-based criteria for managing these types of findings such as, Fleishner criteria for lung nodules.